Sat, 19 Jan 2019 14:38:25 -0800WeeblyWed, 03 Oct 2018 20:52:41 GMThttp://www.medicineandreligion.com/october-blog---benjamin-doolittle/the-cloud-of-the-unknowing-and-the-conundrum-of-medical-diagnosis​“Diligently persevere until you feel joy in it. For in the beginning it is usual to feel nothing but a kind of darkness about your mind, or as it were, a cloud of unknowing. You will seem to know nothing and to feel nothing except a naked intent toward God in the depths of your being. Try as you might, this darkness, and this cloud of will remain between you and your God. You will feel frustrated, for your mind will be unable to grasp him…”[1]

These words come from The Cloud of Unknowing - a manual for contemplative prayer written by a 14th century English cleric whose name we do not know. The 14th century was a rough time in England. The bubonic plague hit the shores in 1348. There was also a cold spell – a mini ice age – that led to reduced crops and widespread famine. It was a rough time.

It is now a Saturday morning. I am attending on the wards. The team leans in towards the MRI images of the lumbar spine. Between L5-S1, there is a spot of bright white where darkness should be. The radiologist’s dictation is equally cryptic - a hedging statement between normal variant, a serious infection, and possible cancer. What to do? In the next patient, there is a soft heart murmur. Last night she spiked a temperature. The blood cultures were positive. Was it a contaminant or an infection of the valve? On another patient, the intern palpates a mass in the chest wall. The patient is here for a completely different reason, but could it be cancer? And on and on it goes….

I picked up The Cloud of Unknowing soon after returning from a pilgrimage to Santiago – the ancient Way of St. James. My youngest daughter and I hiked a modest 90 miles, but it was enough to grow some callouses and unplug from the world a bit. I returned with a renewed joy for classic spiritual works, hoping to preserve the simple gladness of the pilgrim trail. Since the author wrote The Cloud for a young novitiate endeavoring to know God better, I figured it was a good fit. Now, on a Saturday morning, its teaching seemed applicable to my vocation.

The cloud of unknowing refers to the liminal space just prior to full union with God. The author encourages us to “diligently persevere” despite the frustration until, “God in his goodness will bring you to a deep experience of himself.”[2] The cloud of unknowing is a dark, uncertain place of which hints at the angst of existentialists centuries later. There are no easy answers. I find the raw honesty to this prayer manual so refreshing to a modern faith. How can we ever really know the presence of God?

What is more, the cloud of unknowing so aptly describes the practice of medicine – especially the art of medical diagnosis. How can we ever really be sure of our diagnosis? There is so much that is uncertain and vague… so cloud-like. We palpate. We probe. We peer at the scan. And then we decide. ​The 14th century was a controversial time politically and theologically. There were two Popes – one each in Avignon and Rome. John Wycliff translated the Bible into English and was burned at the stake for doing so. Jan Hus led a rebellion against the Catholic Church in Bohemia. The Inquisition was gaining steam. It all sounds so hauntingly familiar.

The real wisdom from The Cloud of Unknowing is not the promise of a eureka moment, but the encouragement to persevere despite uncertainty. This anonymous cleric from the 14th century gives voice to the doubt a puzzled medical team feels when pondering the next medical conundrum. Rarely is there the breakthrough moment, the union with the divine. Patients get better, or they do not. We consult. We biopsy. We treat. And even then, how does the healing really happen?